Inspection·October 17, 2024

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to timely respond to a resident's Power of Attorney after being notified of a concern with a resident's damaged hearing aids. The facility failed to follow their grievance policy. This applies to 1 of 6 residents (R1) reviewed for grievances. The findings include: R1's EMR (Electronic Medical Record) showed R1 had hearing impairment and required the use of bilateral hearing aids. R1's MDS (Minimum Data Set) dated 8/17/2024 showed R1 had moderate cognitive impairment. On 10/15/2024 at 11:55 AM, V6 (Admissions Director) said she received an email on 7/30/2024 from an outside provider regarding V13's (R1's Power of Attorney/POA) concern of R1's missing hearing aids that were found damaged. V6 continued to say she then received another email on 8/03/2024 from V13 regarding her concern with R1's damaged hearing aids and a request to have the facility contact her. V6 said she informed the facility's management team, including V1 (Administrator), on 8/03/2024. On 10/16/2024 at 12:30 PM, V1 (Administrator) said during R1's last care plan meeting on 9/19/2024, V13 again expressed her concern regarding R1's damaged hearing aids. V1 said V13's concern had not been addressed prior because they were informed by an outside provider that R1 possibly damaged her hearing aids herself and then V13 had provided R1 with new hearing aids on 7/25/2024. V1 said the facility did not investigate or interview staff regarding R1's alleged hearing aid incident. The facility's email correspondence from V13 to the facility dated 8/03/2024, showed V13 notified V6 of her concern regarding R1's damaged hearing aids and requested for the facility to contact her. R1's Grievance Concern/Lost Item Form regarding R1's damaged hearing aids was filed on 9/19/2024, which showed a total of 51 days had passed from when the facility was initially notified of R1's concern. The facility's policy titled Grievance Program dated 5/15/2024, said Policy Statement To promote an environment and culture open to feedback positive and or negative from residents, family members, employees, physicians, and any other visitors. Definition: A grievance is a concern that cannot be resolved to the satisfaction of the person making the objection at the bedside and or immediately. Immediately: For the sake of this document, immediately is defined as within four or less hours. 2. Process .When there is a grievance it will be: i. Document on the facility Grievance Report. ii. Routed to the Grievance Officer. iii. Listed on the facility Grievance Tracking Log. iv. Discussed with (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145821 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145821 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pearl of Elgin, The 2355 Royal Boulevard Elgin, IL 60123 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)